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General NPI Number Information
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NPI Number | 1548056922
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Entity Type | Organization
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Legal Business Name | DECATUR FAMILY DENTISTRY 2.0
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Dates
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Enumeration Date | 04/15/2025
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 1020 SOUTHAMPTON DR
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City | DECATUR
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State | IN
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Zip | 46733-1049
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Country | US
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Telephone | 260-223-7533
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Fax |
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Provider Business Mailing Address
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Address Line | 1020 SOUTHAMPTON DR
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City | DECATUR
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State | IN
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Zip | 46733-1049
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Country | US
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Telephone | 260-223-7533
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | FORREST FULLENKAMP
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Credential | DDS
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Telephone | 260-223-7533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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